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Shattered: can the UK’s health recover?

22 November 2021

Some 20 months after the Covid-19 pandemic hit the UK, the damage to the population’s health is already becoming apparent – and it’s looking rather unequal. Journalist Jo Waters explores the impact and way forward.

With some of the world’s higher rates of obesity in adults and children (World Obesity Federation, 2021), rising levels of type 2 diabetes, a growing mental health epidemic – particularly among young people – and widening social inequalities, the UK population was not ideally placed to weather the storm when Covid-19 struck.

In fact, research by a team from the Centre for Longitudinal Studies at the University College London (UCL) Institute of Education (Gondek et al, 2021) revealed that of a cohort born in 1970, a third (33.8%) of the population had already been diagnosed with two or more chronic health problems by 46 to 48 years of age (as seen in the last issue of Community Practitioner).

Some have even argued that the poor overall health of the UK population, coupled with years of underinvestment in the NHS, is why the nation has suffered such a high death toll from Covid-19 – 141,862 (within 28 days of a positive test) at the time of press (UK Government, 2021 ) – and that the pandemic has exposed deep health inequalities as well as exacerbating the population’s poor health (Sample, 2021).

The impact so far

CPHVA Executive chair Janet Taylor, who is also a public health nurse manager in Northern Ireland, says the pandemic has exacerbated existing health problems and social inequalities across the UK, and that the fallout in longer-term health issues is already being seen.

‘What [Covid-19] has done is widened the gap between the haves and have-nots that was already there – those in lower socioeconomic groups have definitely come off worse, and anecdotally at least it seems their health is suffering the most,’ says Janet.

‘For children who were cooped up in flats with no outdoor space or garden alongside school closures, in some cases this resulted in a lack of routine,’ she says. ‘Reduced exercise and easy access to snacks and comfort food will also have impacted on their overall diet.’

Janet also highlights the effect on health of the fear around job losses and furlough for parents, as well as the burden on those working from home ‘who were under pressure to deliver childcare and home schooling to their children, perhaps with limited access to resources such as laptops or the internet’.

‘Social isolation and lack of support from family and friends has affected the mental health of parents and children, resulting in depression and anxiety,’ she continues. ‘We’re already seeing the consequences of the pandemic in terms of impact on long-term health and there’s probably a lot more to come.’

Statistics on the impact of the past 20 months are now beginning to stack up, and the picture they paint is a daunting one. The Office for National Statistics (2021) revealed that the pandemic has undone a decade of improvements in life expectancy, with average levels dropping to where they were 10 years ago. Male and female life expectancy fell in England by 1.3 years and 0.9 years in 2020, reaching their lowest levels since 2011 (Public Health England (PHE), 2021).

Cancer care is one area where the damage of delayed appointments and screening is being felt, while difficulties in getting primary care appointments or patients not wanting to burden the NHS at a time of crisis are also having a big impact. Research by the Institute for Public Policy Research (2021) has estimated that missed referrals mean 19,500 people who should have been diagnosed with cancer have not been. Between March 2020 and February 2021, the numbers of referrals to see a specialist fell by 15%, to 369,000. Some of these ‘lost’ patients will now have incurable advanced cancer. The report said that even if hospitals could increase chemotherapy and radiotherapy treatment by 5% over pre-pandemic levels it would take until 2033 to fully clear the backlog, although a 15% increase could mean the NHS catches up by next year.

It’s a similar story with operations for heart conditions. The British Heart Foundation (BHF) has estimated it could take five years to clear the backlog of cases. Figures for August showed there were 252,354 people waiting for heart tests and treatments – the highest number on record (BHF, 2021). The BHF predicts this will only worsen if the NHS does not get the investment it needs.

 

 

Mental health fallout

Young people seem to have fared particularly badly during the pandemic. The Royal College of Psychiatrists has revealed record numbers of children and young people being referred to mental health services for crisis and non-crisis care. It found 190,271 children and young people under the age of 19 were referred to mental health services between April and June 2021, up by 134% from the same period in 2020 and by 96% from 2019. There was also an 80% rise in the number of young people referred for urgent or emergency crisis care between April and June 2021, and 340,694 children in contact with child and adolescent mental health services (CAMHS) in June 2021, up by 51% from June 2019 (RCPsych, 2021).

Emily Dobson, policy and public affairs manager at mental health charity YoungMinds, says there is a growing body of evidence suggesting the pandemic could have a significant long-term impact on young people’s mental health without the right support.

‘For many young people, even before the pandemic, it was far too hard to get help when they needed it. Support too often focuses on helping those who’ve reached crisis point rather than when problems start to emerge,’ says Emily. ‘When young people can’t get the help they need, their problems often get worse. We hear on our parents’ helpline about children who’ve started to self-harm, become suicidal or dropped out of school while waiting for help. The pressure to support young people often falls on those around them, like their family.’

YoungMinds is calling on the government to invest in a network of early support hubs that offer drop-in services on a self-referral basis for young people struggling with their mental health and wellbeing. ‘Early support hubs can ease the pressure on services and provide accessible support for children and young people in their local area,’ Emily says.

Harriet*, a school nurse working across three secondary schools in London, revealed that these are being totally overwhelmed with the number of young people needing urgent mental health support and safeguarding.

‘The scale of it is like nothing I’ve ever experienced in my 14 years as a school nurse,’ Harriet says. ‘We’re dealing with lots of problems that weren’t picked up during the pandemic – they include neglect and emotional abuse, self-harming cases, anxiety and the effects of isolation.

‘I can’t do any of the preventative work I once did, so I’m no longer a public health nurse in that sense – I’m just firefighting.’

Harriet says that more school nurses and investment in CAMHS have ‘got to be made a priority or there are going to be long term consequences for their mental health’ (see Case study, on page 38).

Faring well or fading fast?

A pre-pandemic report on the health of pregnant women (PHE, 2019) was already flagging up health problems in this group. Concerns particularly centred on obesity as it is associated with stillbirths and complications during labour, with 27.4% of pregnant women classed as overweight, 18.3% as obese and 3.3% severely obese at booking. Women also gained weight between their first and second pregnancies (see Maternal health statistics, right).

Clearly, the past 20 months of interrupted maternity care, with periods of limited face-to-face consultations and antenatal groups, restrictions on hospital visitors and postnatal support, havebeen unlikely to improve the situation.

A study by the University of Bristol (Anderson et al, 2021) concluded that the loss of maternity care and the negative mental health effects of social distancing suggest a growing area of unmet health needs. A report from the Maternal Mental Health Alliance (2021) found that 16,000 women were unable to access essential perinatal mental health care during 2020.

The scale of the problem is like nothing live ever experienced as a school nurse. Were dealing with lots of problems that weren't picked up during the pandemic

Janet says the toll of lockdowns, isolation from family and friend networks, and the fact that at the beginning of the pandemic partners could not be with mothers for appointments and scans or until labour was established, plus the anxiety surrounding the effects of Covid-19 on pregnant women and newborns, were bound to have had lasting effects. ‘For some, not all, these effects will be irreversible because they can’t get that time back,’ she says.

‘Pregnant women and new mothers suffered in many ways during the pandemic; they missed out on the support that is so important by meeting face to face in a group,’ Janet adds. ‘That included some antenatal classes, visits from family and friends, and peer support from breastfeeding groups and postnatal groups.

‘Although support was available online, this doesn’t suit everyone – particularly those who are unwell,’ she says.

‘Babies and toddlers have also missed out on being socialised, [so] it’s very important this happens now – health visitors are the key professionals who can help these families,’ Janet continues. ‘But in England at least, we’re hearing they still have huge caseloads, which is terribly frustrating as we need more, not fewer, health visitors and more investment.’

Hilary*, an HV in London, believes the pandemic’s legacy will be greater uncertainty, confusion and isolation among pregnant women, and delays in child development.

‘Pregnant women have had heightened anxiety around fear of catching Covid-19 and not seeing health professionals face to face during pregnancy,’ says Hilary. ‘They are also still worried that their partner may not be able to be present during and after delivery, as was the case at the beginning of the pandemic.’

Hilary says many of the women she visits have families abroad, who would have planned to come and stay after delivery. This has not been possible, and along with the closure of children’s centres has left first-time mothers feeling isolated and unsupported.

She also reports a huge increase in safeguarding and/or domestic violence in families where overcrowding and loss of jobs and income during lockdown have raised stress levels at home.

 

 

‘We only see the tip of the iceberg, but now schools have reopened, many more cases will come to light as children disclose their home situation to their teachers,’ Hilary says.

Middle-age spread of disease

A poll of 5000 people conducted this summer found that 41% of respondents had put on weight since March 2020, with an average weight gain of 4kg (Clinton, 2021). This is just one snapshot of how lockdowns have affected the nation’s health.

However, multiple chronic diseases are also affecting the population. Researchers from Newcastle University have used modelling to predict that multimorbidity prevalence is estimated to increase between 2015 and 2035, with the proportion of people with four or more diseases almost doubling (Kingston et al, 2018). 

Dawid Gondek, a research fellow at UCL’s Department of Epidemiology and one of the authors of the 1970 cohort study, says that hospitalisation tends to exponentially increase with age, rapidly accelerating from age 50.

‘It’s quite likely that these conditions, which are potentially not as severe in midlife, may result in a high burden on the NHS when this cohort gets into their older age,’ explains Dawid. ‘Polypharmacy is one of the key problems of multimorbidity, requiring coordination of care across various medical professionals.

‘Midlife is typically considered as a stage with still relatively good health, so the fact that already one-third of the population has multimorbidity is not a very positive prognostic for the future.’

Dawid says it is difficult to pinpoint exactly what is fuelling the increase in multimorbidity, but obesity plays a role. ‘There is increasing evidence that other factors are important, such as air quality, diet (including increased intake of processed food) and an inactive lifestyle,’ he says.

‘There is also more and more evidence that mental health gets worse over time, which is an important component of multimorbidity and is itself a risk factor for physical health – including mortality,’ Dawid adds.

Although Dawid says intervention could change people’s health outcomes, the timing is important: ‘Any time for intervention is good; but overall, there’s increasing consensus that the earlier we act, the better. Childhood obesity or poor mental health increases the risk of various other health or social problems for a person’s entire lifespan.

 

‘The majority of adults with depression were depressed already as children or adolescents. Hence, acting early and focusing on prevention may have greater benefits. However, this does not mean that nothing can be done in midlife. We already know that exercising, eating healthily and remaining socially active in older age – for instance, through volunteering or art – is good for both mental and physical health.’ 

Get healthier and buck the trend

The government is taking steps to try and tackle ill health. In July 2020, PHE launched its Better Health campaign to help the public lose weight with the help of phone apps, TV advertising and healthy recipes. The move is part of its wider anti-obesity strategy – promoting personal responsibility for health. It has also recently voted to introduce a new health and social care levy to help pay for the costs of Covid-19 (UK Parliament, 2021).

The government’s commitment to a ‘levelling up’ agenda also purports to tackle wider social inequalities, which are the biggest cause of ill health. Health secretary Sajid Javid acknowledged this when he told an event at the Conservative Party conference in Manchester in October that Covid-19 had laid bare the UK’s underlying health inequalities and the virus proved life chances varied greatly depending on where a person lives.

However, Dr Jennifer Dixon, chief executive of the Health Foundation, responded by saying health funding has been cut by more than £1bn in the past 10 years and further cuts have been made to services that are fundamental to people’s health, such as education and housing. ‘The level of basic income also impacts health and the end to Universal Credit uplift of £20 per week will impact the poorest and sickest in England. Government investment is now needed to reverse the trend,’ she says.

Meanwhile, a new report from the House of Commons Petitions Committee (2021) has rebuked the government for failing to help young families. The report says that, after 18 months of restrictions, new parents are now facing ‘an accumulation of adversity’.

The report said: ‘Our witnesses identified a clear need for the government to focus not only on restoring services such as health visiting and maternal mental health services to their pre-pandemic levels, but also ensuring urgent catch-up support is available for parents who have missed out on support over this time.’

Dr Megan Watson, public health intelligence adviser at Public Health Scotland (PHS), says her organisation is working with partners in national and local government, the voluntary sector and in communities to monitor the impact of Covid-19 on children and families in Scotland while providing evidence to support ongoing measures to protect people’s health and wellbeing. PHS ran two national surveys between June and December 2020 to hear directly from parents and carers of children aged two to seven about how the pandemic had affected their families.

‘These findings highlighted inequalities in psychological and emotional wellbeing and access to outdoor and greenspace among children, as well as inequalities in parental mental health,’ says Megan. ‘Our findings crucially informed local and national policy and practice – for example, decisions on the reopening of parks and not restricting the number of young children that could meet outdoors.’

PHS is now running its Covid-19 Early Years Resilience and Impact Survey for a third time. It wants to find out about the experiences of more children and to know how things are for families now. ‘We are asking parents/carers of children aged 0 to 11 to complete the survey, even if they have completed them before,’ Megan says. ‘Knowledge of how families are doing now, and if they are continuing to be affected by the pandemic, will help public services to best meet the needs of children and protect their learning and healthy development.’

Public Health Wales has already published a report on tackling health inequalities (2021). Strategies include making more use of digital technology to support young people’s mental health and straddle the digital divide. Another example was a national telephone befriending service for older people and a Looking Out For Each Other Safely campaign, which provides advice on how to stay in contact and prevent feelings of loneliness and isolation.


Case study

Harriet*, a school nurse working in three secondary schools in London, shares her concerns.

‘Children with significant mental health problems are not being seen soon enough. I get where CAMHS is – the backlog is huge – but it’s so frustrating as kids end up having to go to A&E in a crisis that could have been avoided if they’d been seen sooner. On a personal level, it’s a massive responsibility; I feel guilty when I can’t help children as much as I’d like and fear what will happen if they fall through the net.

‘We desperately need more school nurses and investment in CAMHS to support young people who have been through so much in their adolescence.

‘At a personal level, I feel burnt out and out of my depth, and have actually moved down a band so I have less responsibility. I’ve found it all a big strain.’


More investment needed

While of course individuals have responsibility for their own health too, it seems perhaps that this is not the greatest determinant. Janet says the poorest families will be hit by the perfect storm of Universal Credit cuts and rocketing fuel bills this winter – and both will affect families’ health as they will have less to spend on food and suffer more stress from balancing their budgets. ‘None of these pressures help families become more healthy,’ she adds. ‘Footballer Marcus Rashford’s campaign for free school dinners in the summer holidays highlighted just how up against it many families are.

‘To improve the nation’s health, we need more investment in health services, including more health visitors and school nurses to help with tackling problems such as childhood obesity and poor mental health, and also a fairer, more equal society.’

Dawid agrees: ‘Probably the strongest determinants of poor health are socioeconomic circumstances, such as income or neighbourhood inequalities, which are related to access to healthy food, green space or having free time to adopt a healthy lifestyle. Reducing inequality would speculatively lead to greater public health benefits.’


Resources


References:

Anderson E, Brigden A, Davies A et al. (2021) Pregnant women’s experiences of social distancing behavioural guidelines during the Covid-19 pandemic ‘lockdown’ in the UK, a qualitative interview study. BMC Public Health 21(1): 1202.

British Heart Foundation. (2021) Waiting lists for vital heart care rise to record level again in England. See: bhf.org.uk/what-we-do/news-from-the-bhf/news-archive/2021/august/nhs-england-waiting-time-heart-care-june (accessed 5 October 2021).  

Clinton J. (2021) Summer health drive in England as 40% say they gained weight in lockdown. The Guardian. See: theguardian.com/society/2021/jul/26/summer-health-drive-in-england-as-40-say-they-gained-weight-in-lockdown (accessed 5 October 2021).

Gondek D, Bann D, Brown M et al. (2021) Prevalence and early-life determinants of mid-life multimorbidity: evidence from the 1970 British birth cohort. BMC Public Health 21(1): 1319.

House of Commons Petitions Committee. (2021) Impact of Covid-19 on new parents: one year on. See: https://publications.parliament.uk/pa/cm5802/cmselect/cmpetitions/479/47902.htm (accessed 7 October 2021).

House of Lords Library. (2021) Social care funding: a rise in national insurance. See: https://lordslibrary.parliament.uk/social-care-funding-a-rise-in-national-insurance/ (accessed 5 October 2021).

Kingston A, Robinson L, Booth H et al. (2018) Projections of multi-morbidity in the older population in England to 2035: estimates from the Population Ageing and Care Simulation (PACSim) model. Age and Ageing 47(3): 374-80.

Office for National Statistics. (2021) Life expectancy for local areas of the UK between 2001 to 2003 and 2018 to 2020. See: ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/lifeexpectancyforlocalareasoftheuk/between2001to2003and2018to2020 (accessed 5 October 2021).

Patel P, Thomas C. (2021) Building back cancer services in England. Institute for Public Policy Research. See: www.ippr.org/files/2021-09/building-back-cancer-services.pdf (accessed 5 October 2021).  

Public Health England. (2021) Health profile for England 2021. See: https://fingertips.phe.org.uk/static-reports/health-profile-for-england/hpfe_report.html (accessed 7 October 2021).

Public Health England. (2019) Health of women before and during pregnancy: health behaviours, risk factors and inequalities. See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/844210/Health_of_women_before_and_during_pregnancy_2019.pdf (accessed 5 October 2021).

Public Health England. (2020) Major new campaign encourages millions to lose weight and cut Covid-19 risk. See: gov.uk/government/news/major-new-campaign-encourages-millions-to-lose-weight-and-cut-covid-19-risk (accessed 5 October 2021).

Public Health Wales. (2021) Placing health equity at the heart of Coronavirus recovery for building a sustainable future for Wales. See: https://phw.nhs.wales/news/placing-health-equity-at-the-heart-of-coronavirus-recovery-for-building-a-sustainable-future-for-wales (accessed 5 October 2021).

Royal College of Psychiatrists. (2021) Record number of children and young people referred to mental health services as pandemic takes its toll. See: rcpsych.ac.uk/news-and-features/latest-news/detail/2021/09/23/record-number-of-children-and-young-people-referred-to-mental-health-services-as-pandemic-takes-its-toll (accessed 5 October 2021).  

Sample I. (2021) UK health inequalities made worse by Covid crisis, study suggests. The Guardian. See: theguardian.com/world/2021/jun/14/uk-health-inequalities-made-worse-by-covid-crisis-study-suggests (accessed 6 October 2021).

Tubb A. (2021) 16,000 women were unable to access essential perinatal mental health care due to the pandemic, according to research. Maternal Mental Health Alliance. See: https://maternalmentalhealthalliance.org/news/mums-unable-access-essential-perinatal-mental-health-care-in-pandemic/#more-8524 (accessed 5 October 2021).

UK Government. (2021) Deaths in the United Kingdom. See: https://coronavirus.data.gov.uk/details/deaths  (accessed 5 October 2021).

World Obesity Federation. (2021) Ranking (% obesity by country). See data.worldobesity.org/rankings/?age=a&sex=m (accessed 6 October 2021).

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